Steven R. Steinhubl, MD December 1, 2015

mHealth: Enabling the

Re-engineering of

Healthcare

“mHealth (or mobile health) is the use of mobile or wireless devices to improve health outcomes, healthcare services and health research.”

-NIH Consensus group

What is mHealth?

mHealth: Enabling the Re-

Engineering of Healthcare

1. Technology progress, in perspective.

2. Where can mHealth make a difference?

3. The changing landscape of healthcare.

4. Challenges to adoption.

mHealth: Enabling the Re-

Engineering of Healthcare

1. Technology progress, in perspective.

2. Where can mHealth make a difference?

3. The changing landscape of healthcare.

4. Challenges to adoption.

ASCI Red

• World’s fastest super-computer in 1996 – 1.8 teraflops/sec (1.8 trillion operations /sec)

• $55 million to develop.

• Occupied 1,600 square feet of floor space.

• Used 800 KW/hr (~800 homes)

• 2006 – 1.8 teraflops/ sec

• $500

• 200 watts

• 64 million units sold

May, 1997 IBM’s Deep Blue beat World Chess Champion Garry Kasparov.

Deep Blue

Watson is now “…the size of three pizza boxes stacked up. It's also 24 times faster and has seen a 2,400 percent improvement in performance.”

2012

KPCB, 2014

PC

Smartphones Tablets

http://www.nydailynews.com/news/world/check-contrasting-pics-st-peter-square-article-1.1288700#ixzz2ePFO9300

194 minutes a day looking at smartphone or tablet screen. 147 looking at TV, 103 at laptop or PC.

In the US, 91% of adults own a mobile phone, with the

majority of them (61%) being smartphones.

Projected Worldwide Growth in Mobile & Smartphones

Ericsson Mobility Report June 2014

A Historical (and Present Day) Look at Our Tools for a Patient’s Office Visit

Blood Pressure

ECG

Physical Exam/Auscultation

House Calls

• Sphygmomanometer invented 1881.

• Popularized by Harvey Cushing 1901

1904

• Willem Einthoven 1901.

• Precordial leads introduced 1944

1911

• Laënnec 1816.

• Binaural stethoscope 1851

1852

~1900

• In 1930’s ~40% of all patient encounters were in their home.

Unwin BK. Am Fam Physician 2011

mHealth: Enabling the Re-

Engineering of Healthcare

1. Technology progress, in perspective.

2. Where can mHealth make a difference?

3. The changing landscape of healthcare.

4. Challenges to adoption.

Science Trans Med April 15, 2015

The Near Future of Wearable Sensor Data 1. Activity

2. Pulse

3. Sleep stages

4. Blood pressure

5. Cardiac Output / Stroke Vol.

6. ECG

7. Stress HRV EDA

8. Respiration rate

9. Oxygen saturation

10. CO2 levels

11. Temperature

12. Hydration

13. Glucose (?)

Oura Ring

Measures:

• Heart rate

• Respiration rate

• Body temperature

• Movement.

Algorithms interpreting sleep cycles closely match analysis done at sleep laboratories.

Predicted Growth in Wearables

Gartner's 2014 Hype Cycle for All Emerging Technologies

http://www.gartner.com/newsroom/id/2819918

There Remain Huge Gaps in People-

Centered Care Availability

Nielsen’s Strategic Health Perspectives June 2015 http://goo.gl/P0gZYl

Online survey of 5,014 US adults Access to Interactions with Primary Care

Acute Diagnostics, When and

Where They are Needed More than a million people are searching on Google for information on ear infection at 4:30 a.m. every morning

Ryan Olohan, Industry Director, Healthcare. Google Inc. October 2015

The Stethoscope as a Relic of

the Past

Auscultation skills in 860 providers:

Trainees thru Faculty

Sensitivity Specificity

Systolic 84% 35%

Diastolic 49% 67%

Vukanovic-Criley JM. Arch Intern Med. 2006;166(6):610-616

Hypertension Management - Why Important?

1. One of every 3 adults in America has high BP. 1

2. Nearly $100 billion in total costs are attributed to high BP annually in the US. 2

3. Nearly 40 million office visits every year in the US have a primary diagnosis of hypertension making it the single most common reason for an office visit.3

4. Less than half of all individuals in the US have their blood pressure under control, and only 20% worldwide.1

1. MMWR. Morbidity and mortality weekly report 2011;60(4):103-108. 2. Heidenreich PA. Circulation 2011;123(8):933-944. 3. National Ambulatory Medical Care Survey: 2010 Summary Tables.

Global Burden of Disease Attributable to 20 Leading Risk Factors (2010)

Lim SS. Lancet. 2012; 380: 2224–2260.

Improved Blood Pressure Control with Self-Monitoring and Self-Treatment

Simplified and Connected HTN Management

Wellness

Diabetes

Respiratory

Home Diagnostics

Hypertension

Healthcare Team

Physician, nurse, pharmacist, dietician,

physical therapist, IT…

Personalized Predictive Analytics Automated Clinical Decision Support

Learning Healthcare System

Mobile Phone Penetration in Sub-Saharan Africa

mHealth: Enabling the Re-

Engineering of Healthcare

1. Technology progress, in perspective.

2. Where can mHealth make a difference?

3. The changing landscape of healthcare.

4. Challenges to adoption.

Separating the Wheat from the

Chaff When There is Mostly Chaff Number of Health Related Apps Now >165,000

• 100% increase in the number of iOS apps over last 2 years

• Only 0.02% (36) of all apps account for 50% of downloads.

• Only 2% provide connectivity with provider healthcare systems.

“Patient Adoption of mHealth” IMS Institute for Healthcare Informatics. Sept 2015

Estimated Total Downloads of

mHealth Apps (billions)

Copyright research2guidance 2015

Online Consumer Survey of

395 Respondents

Consumer Health Information Crop. http://www.consumer-health.com/motivating-patients-to-use-smartphone-health-apps/ April 21, 2011

• 26% of apps are downloaded and used only once.

• Of the people who confirm using their apps, 74% drop out by the 10th use.

• Also showed that 26% of smartphone apps retain consumer loyalty.

Digital Snake Oil

Digital Snake Oil

“The $2.8 trillion US healthcare

industry is being upended by companies

attuned to the needs and desires

of empowered consumers.”

pwc. Health Research Institute April 2014. Healthcare’s new entrants: Who will be the industry’s Amazon.com?

• ~1000 locations in 31 states

• Staffed by nurse practitioners and physician assistants

• Over 25 million patient visits since 2002.

• 400 Healthcare Clinic locations across US

• Most used healthcare app

• Already collecting mHealth data remotely in 800,000 individuals with 250,000 connected devices in their for Balanced Rewards for healthy choices loyalty program.

• Primary provider of flu vaccines in the country.

Becker’s Hopsital Review Feb 2014

Do Virtual Visits Impact Care

Delivery? UTI Complaints

Mehrotra A. JAMA Intern Med. 2013;173:72-74 , Figure from WSJ

• No difference in the rate of f/u visits (7% for both) as a proxy for treatment failure.

• Not examining a patient may lead to a more “conservative” treatment approach.

Compared 2855 office visits to 99 “e-visits.”

mHealth: Enabling the Re-

Engineering of Healthcare

1. Technology progress, in perspective.

2. Where can mHealth make a difference?

3. The changing landscape of healthcare.

4. Challenges to adoption.

Guiding Principles “…high quality adequately powered trials of optimised interventions are required to evaluate effects on objective outcomes.”

“The paucity of evidence calls for much needed future research...”

“High quality trials measuring clinical outcomes are needed.”

January 2013

January 2013

So How Do We Show True Value? Productivity Paradox

Electric Dynamo Steam Engine

David Paul A. American Economic Review 1990;80:355-61

• In 1900 95% of all factory

machines were still steam

engine and belt driven (two

decades after Edison’s first

electric power system

started).

• It took ~ 40 years to see

meaningful productivity

gains as the original group

drive system remained in

place for much of that time.

So How Do We Show True Value? Productivity Paradox

David Paul A. American Economic Review 1990;80:355-61

Just as systems of manufacturing

needed to change to take

advantage of transformational

technology, systems of care need

to be re-engineered around the

capabilities that mHealth tools

provide.

• We are well into a technology revolution of unprecedented computational power & connectivity that we are just now beginning to leverage for healthcare.

• The availability and variety of wearable sensors for health and wellness is rapidly increasing, although with limited clinical uptake.

• Consumer-facing, non-traditional providers may be in a stronger position to lead the transformation of healthcare in the US than are legacy healthcare systems.

• mHealth technologies can enable, but alone will not drive the complete re-engineering of the healthcare landscape.

The mHealth: Enabling the Re-

Engineering of Healthcare - Summary